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Management Of Intraoral Sinus Tract By Single Visit Endodontics

Presented by : Dr. Aditya Shinde.Guided by : Dr. Lalitagauri Mandke.

Case Report :-

Patient name :- XYZ

Age :- 49 yrs

Address :- Rabale

Chief Complaint:- Decay and Pain in upper back right region followed by the pus drainage since two weeks.

Past dental history :- h/o of extraction in relation to #15 , 3 years ago.

No relevant medical history.

Clinical Examination :-On extraoral Examination:- Lymph node were not palpable , no external swelling or sinus seen.

On intraoral examination:- deep proximal caries related to #14.

draining sinus seen on labial mucosa in relation with #14.

On evaluation on IOPA:- periapical radiolucency seen around #14

RVG showing #25 GP tracing the sinusIntraoral picture

Sinus tract tracing !• To trace the sinus tract a size#25 gutta percha cone was

threaded into the opening.• Gutta percha cone was inserted untill the resistance was felt.• After that periapical radiograph was taken to determine the

path and termination of the sinus tract.• The cone extended till the palatal root of #14, thus

confirming that sinus was related to #14.

Provisional Diagnosis

CHRONIC PERIAPICAL ABSESS IN RELATION TO #14

Treatment plan :-

• Single sitting root canal treatment

Treatment :- • Root canal treatment of #14 was proposed to the patient and treatment

was initiated.

• Caries excavation was done using spoon excavator & round carbide bur.

• Access cavity was made using endo-access bur (DENTSPLY mailefer).

• Buccal and palatal canal orifices were located and canals were traced.

• Working length was determined using Root ZX mini apex locator (J MORITA, Japan) and confirmed on RVG.

• Cleaning and shaping was done using K files (MANI) and hand protaper (DENTSPLY) with crown down technique.(enlarged till F1).

• During cleaning and shaping recapitulation and copious irrigation was done with saline.

MASTER CONE RADIOGRAPH WAS TAKEN USING F1 GUTTA PERCHA CONE.APICAL TUGBACK WAS ALSO CONFIRMED.

Working length radiograph

Master cone radiograph

Final irrigation protocol:- saline + sodium hypocholrite

Canals dried with paper points.

Zinc oxide eugenol cement used as sealer.

Obturation done using lateral condensation method.

Temporary restoration given to seal access cavity. Obturation RVG

Prescribed antibiotics and analgesics

Patient was advised to gargle twice a day with warm water with salt.

Patient was recalled for check up after one week.

It was observed that the sinus had resolved and patient was asymptomatic, post obturation restoration was done with composite resin cement.

Post obturation After one week RVG

Introral healing seen in one week

Radiograph after one month follow up

Discussion :-

• On occasion a chronic endodontic infection will drain through a intraoral communication to the gingival surface and is known as a sinus tract. This pathway, which is sometimes lined with epithelium extends directly from the source of the infection to a surface opening, or stoma, on the attached gingival surface.

• In general, a periapical infection that has an associated sinus tract is not painful, although often there is history of varying magnitude before the sinus tract developed. Besides providing a conduit for the release of infection exudate and the subsequent relief of pain, the sinus tract can also provide a useful aid in determining the source of given infection.

• The stoma of the sinus tract may be located directly adjacent to or at a distant site from the infection. Tracing the sinus tract will provide the objectivity in diagnosing the location of the problematic tooth.

• Carious exposure with bacterial invasion of the tooth pulp leading to a

periapical abscess is the most common cause of dentocutaneous sinus tracts. The inflammation destroys the cancellous alveolar bone and proceeds along the periosteum until perforation occurs. An intraoral or extraoral sinus can develop, depending on the path of the inflammation, which is dictated by surrounding muscular attachments and fascial planes. For example, if the bone perforation on the mandible occurs above the muscular attachment, then an intraoral sinus will result. If the perforation occurs below the level of muscular attachment, then a cutaneous sinus will result.

• To trace the sinus tract a size #25 gutta percha cone is threaded into the opening of the sinus tract. The cone should be inserted until the resistance is felt, after which a periapical radiograph is taken. This will direct the clinician to which tooth is involved and more specifically, which root of that tooth is the source of the pathosis.

• The stomata of intraoral sinus tracts may open in the alveolar mucosa, in the attached gingiva, or through the furcation or gingival crevice. They may exit through either the facial or lingual tissues depending on the proximity of the root apices to the cortical bone.

• Indications for SVE:- 1. Vital teeth. 2. Fractured anterior where esthetics is the concern.3. Patients who required sedation every time.4. Non-vital teeth with sinus tract.5. Teeth with limited access.6. Nonsurgical retreatment cases.7. Medically compromised patients who require antibiotics prophylaxis. 8. Physically compromised patients who can not come to dental clinics

frequently.

• Single sitting endodontics implies to cleaning, shaping and disinfection of root canal system followed by obturation of the root canal at the same appointment.

• Criteria for case selection as given by Oliet include:-1. Positive patient acceptance.2. Absence of acute symptoms.3. Absence of continuous hemorrhage or exudation.4. Absence of anatomical interference like presence of fine, curved or

calcified canals.5. Availability of sufficient time to complete the case.6. Absence of procedural difficulties like canal blockage, ledge formation

or perforation.

• Single-visit endodontic treatment and multiple-endodontic treatment have their advantages and disadvantages. In general, many dentists considered the single-visit approach to be an alternative to a multiple-visit but have no trouble replacing it. The success of endodontic treatment should be based on careful case selection. There should be no shortcuts in any of the steps throughout the treatment procedures. Clinicians should evaluate their own clinical skills and the needs of the patient. Notwithstanding the single-visit treatment approach, the clinicians should directly follow endodontic principles.

• It has been suggested that the teeth with chronic apical periodontitis and a draining sinus tract can be endodontically treated by a single visit procedure. This sinus tract may act as a safety valve for the residual inflammatory exudate. But a Cochrane systemic review showed that there was no study which had investigated fistulas or sinus tract formations with respect to a single-visit versus multiple-visit endodontic treatment. 

Conclusion :-Single visit endodontics has been shown to be an effective treatment modality, which, when compared to multiple visit therapy, is more beneficial to patients and dentists in many ways provided there is a careful case selection and adherence to standard endodontic principles . The prevention and elimination of apical infection are the goal of a successful endodontics therapy, once the way to accomplish these goals is determined, the decision to provide treatment in multiple visit or single visit will follow itself.

The following case shows successful management of periapical infection with sinus by single visit endodontic therapy.

References :-• Pathways of Pulp – Stephen Cohen, Kenneth M. Hargreaves , 10th edition.

• Problem Solving In Endodontics – James Gutmann - 5th edition.

• Endodontics – John Ingle – 6th edition.

• Textbook of Endodontics - Nisha Garg, Amit Garg - 2nd edition.

• Clinical efficacy of treatment procedures in endodontic infection control and one year follow-up of periapical healing. Waltimo T, Trope M, Haapasalo M, Ørstavik D. J Endod. 2005;12: 863-66 .

• Single or multiple visit endodontics: which technique results in fewer postoperative problems. Int Endod J. 2008;2: 91-99 .

• Single versus multiple visits for endodontic treatment of permanent teeth. Figni F, Lodi G, Gorm F, Gagliani M. Evidence based dentistry. 2008;1:24

• Cutaneous Draining Sinus Tract of Odontogenic Origin: Unusual Presentation of a Challenging Diagnosis. sheehan Dj;pPotter BJ;Davis LS. South med j.2005;98(2):150-152

 • “Non surgical management of cutaneous sinus tract of dental origin: a

report of three cases”. Rohit Kansal, Aishvarya Kaushik, Sangeeta Talwar, Sarika Chaudhary, Ruchika Nawal . Journal of Evolution of Medical and Dental Sciences 2013; Vol. 2, Issue 46, November 18; Page: 9042-9047

• Non-Surgical Management of Mandibular Molar with Multiple Intra–oral Sinus Tracts: A Case Report. G.Ruchi, V Prakash j clin dian res 2013 oct;7(10)2392-2393.

• Asystematic review of nonsurgical single-visit versus multiple-visit endodontic treatment , Amy WY Wong , Chengfei Zhang , and Chun-hung Chu; Clin Cosmet Investig Dent. 2014; 6: 45–56.

• Management of an Endodontic Infection with an Intra Oral Sinus Tract in a Single Visit: A Case Report . Krishnamurthy Satish Kumar , Arunajatesan Subbiya , Paramasivam Vivekanandhan,Venkatachalam Prakash, andRamachandran Tamilselvi , J Clin Diagn Res. 2013 Jun; 7(6): 1247–1249.

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